ANAESTHESIA FOR

THYROID SURGERY
DR. PRAVEEN R
 INTRODUCTION

• Thyroid surgeries can range from simple removal of a thyroid nodule to TOTAL
THYROIDECTOMY.

• Thyroidectomy is the commonest endocrine surgical procedure being carried

out throughout the globe.

• The commonest implications during such procedures involve the management

of a potential difficult airway, especially in cases of retrosternal goiter, and a
large thyroid mass compressing over the trachea for a prolonged duration.

• Moreover, there exists a potential risk of uncontrolled hemorrhage as the

major vessels lie in the vicinity of thyroid gland.
 CONSIDERATIONS

• Preoperative assessment of thyroid function

• Anticipated difficult airway

• Adequate surgical relaxation

• Postoperative urgent airway complications (hematoma, bilateral vocal palsy)

 PREMEDICATIONS
• It is fundamental to ensure that patients are euthyroid prior to an elective thyroid
surgery.

• Usual antithyroid medications should be continued on DOS except for

Carbimazole as it increases the vascularity of the gland.

• Benzodiazepines may be administered for anxiolysis but should be avoided if

there is any airway concern.

• Anticholinergics may be helpful to dry secretions if a fibreoptic technique is

planned.

• H‑2 blockers like ranitidine are safe along with metoclopramide when
administered preoperatively.
 In emergency surgery

• It may not be possible to achieve a euthyroid state in patients with

uncontrolled thyroid disease..

• In these circumstances, hyperthyroid patients should have immediate

control of symptoms with beta blockade (e.g. propanolol, esmolol),
intravenous hydration and active cooling if necessary.

• Severely hypothyroid patients are at risk of perioperative myxoedema

coma and can be treated with intravenous T3 and T4.
 ADMINISTRATION OF ANAESTHESIA

• GA is the preferred technique but regional anaesthesia can still have a

place either as a sole technique or alongside GA to enhance analgesia.

• Commonly used techniques include bilateral C2-C4 superficial cervical

plexus block and cervical epidural.

• Regional anaesthesia avoids the risks associate with GA, allows

intraoperative voice monitoring and provides excellent postoperative
analgesia.

• But it has a higher incidence of complications including vertebral artery

and subdural injection, and notably bilateral phrenic nerve palsy.
 GENERAL CONSIDERATIONS IN GA
• In most cases, the preferred method is intravenous induction and intubation with a
reinforced tube.

• If there is anticipated difficult airway concern, an awake fibreoptic intubation may be

used.

• A difficult airway trolley should be made ready.

• Small size flexometallic tubes should be kept handy.

• Equipments for cricothyroidotomy/ tracheostomy should be available.

• Pre‑oxygenation with 100% oxygen enhances the FRC and provides enough time for
securing the access to difficult airway.
• Shorter acting opioids such as fentanyl, remifentanyl, sufentanyl should preferably
be used.

• Thiopentone sodium and Propofol are the induction agents of choice.

• In a difficult airway scenario, succinylcholine remains the drug of choice, but

ideally vecuronium is the preferred muscle relaxant because of its cardio‑stability
characteristics.

• Intra‑op steroids are helpful in prevention of airway edema and reduce the
incidence of postoperative nausea and vomiting (PONV) as well.
 HYPERTHYROID PATIENTS
• Elective surgery should be done after 4-6 weeks therapy with methimazole or propylthiouracil as
there are large stores of thyroid hormone.

• In emergency, beta blockers like esmolol is titrated to control the heart rate. Esmolol is
administered in the dose of 0.5mg/kg IV followed by an infusion of 0.03-0.3mg/kg/min.

• Benzodiazepines reduce anxiety and catecholamine release.

• Anticholinergic premedications cause tachycardia and alter the heat regulating mechanisms and
are best avoided.

• Medications with sympathetic or sympathomimetic effects (eg, epinephrine, ephedrine, ketamine

, or atropine) may result in exaggerated responses; thus, these drugs are avoided if possible.

• Hypotension should be treated with direct-acting vasoconstrictors (eg, phenylephrine), rather

than medications that increase catecholamine release.
• INDUCTION AGENTS:

• Thiopentone decreases the peripheral conversion of T4 to T3 and is preferred.

• Propofol can also be used. Clearance and distribution volume is increased in

hyperthyroid patients; so increased doses may be needed.

• Ketamine is avoided due to its sympathomimetic action.

• Maintaining a deep plane is necessary to avoid symapathetic responses to

surgical stimulation (eg, tachycardia and hypertension).

• Hyperthyroidism does not increase minimum alveolar concentration (MAC)

requirement. Isoflurane and Sevoflurane can be used safely in these patients.
 THYROID STORM
• It is a life threating condition where exacerbation of the hyperthyroid state is
precipitated by acute stress like infection, trauma and surgery.

• Tachycardia, arrythmia and hyperthermia are the classical signs intraoperatively.

• Differential diagnosis: Malignant hyperthermia, neuroleptic malignant syndrome,

pheochromocytoma.

• Management: Treat the pecipitating cause, fluid resuscitation, cooling measures.

• Pharmacological management: IV beta blockers, propylthiouracil, sodium iodide

and IV steroids.
 HYPOTHYROID PATIENTS
• Hydrocortisone cover should be given as there is increased incidence of adrenocortical
insufficiency and reduced response to stress.

• Sedative premedications should be avoided as they show increased sensitivity to sedative and
anaesthetic drugs.

• Propofol is a safe choice and should be used in titrated doses.

• Chemoreceptor responses are blunted increasing the risk of respiratory depression. Short acting
opioids (Fentanyl) should be used in small titrated doses.

• There is no evidence that these patients have reduced MAC requirements.

• Warming measures should be instituted to prevent hypothermia.

 MONITORING

• Patients with well-controlled thyroid disease need only standard monitors

including ECG, NIBP, pulse oximetry, and capnography.

• Patients who remain hyperthyroid at the time of surgery may benefit from
invasive monitoring of blood pressure with an intra-arterial catheter, in order to
immediately detect and treat hyper- or hypotension.

• Monitoring of temperature is significant as there are potential risks of developing

hyperthermia or hypothermia.
 POSITIONING
• For optimal surgical access the head is fully extended and rested on a padded ring with
a sandbag between the scapulae.

• The gravitational drainage of the blood from the surgical site by a head‑up position is a
desirable feature and can be practiced.

• The eyes should be adequately padded and particular attention paid to those with
exophthalmos.

• Access to the airway will be limited during the procedure, so the endotracheal tube
should be taped securely.

• As the arms are extended by the patient’s side, long extension leads on the drips are
useful.
 EMERGENCE
• Neuromuscular blockade should be fully reversed and endotracheal tube cuff deflated to ensure a leak prior to
extubation. The possibility of tracheolmalacia should be kept in mind.

• The prevention of stress response during extubation is widely appreciable as it can avoid any accidental hemorrhage
from the wound site.

• Dexmedetomidine has a significant role in attenuation of stress response during these procedures. IV lignocaine can
also be used.

• If the vocal cords have been sprayed with lidocaine at intubation, this may also help to achieve a smooth emergence.

• Extubation should be performed after adequate preoxygenation and with all preparation for reintubation if required.

• At the end of the procedure the surgeon may request a Valsalva manoeuvre to check for haemostasis.

• If there have been any concerns regarding the integrity of the recurrent laryngeal nerve, then the vocal cords are
visualised with either a laryngoscope, or a fibreoptic scope via an LMA.
 ANALGESIA

• Infiltration with local anaesthetic and adrenaline subcutaneously prior

to incision confers some analgesic effect into the postoperative
period.

• Regular paracetamol, non-steriodal antinflammatories (NSAIDs) with

intermittent opioids are usually adequate.

• Administration of antiemetics is important as these patients are at

high risk of postoperative nausea and vomiting.
 POSTOPERATIVE CONSIDERATIONS
• HAEMORRHAGE:

• It is a common post‑op complication and can cause compression over the neck structures,
leading to acute airway obstruction.

• The patient’s airway should be immediately decompressed by removal of surgical clips. If there
is time to return to theatre, reintubation should be performed early.

• LARYNGEAL EDEMA:

• It is frequently caused by multiple attempts at laryngoscopy during difficult intubation or due to

venous obstruction of laryngeal vessels by an enlarging hematoma.

• It can usually be managed with steroids and humidified oxygen. If edema leads to stridor,
intubation with ETT is mandatory.
• RECURRENT LARYNGEAL NERVE (RLN) PALSY:

• Damage to RLN can be caused by traction, transaction, entrapment or ischemia and can be permanent or transient.

• Unilateral vocal cord palsy will present with respiratory difficulty, hoarse voice or difficulty in phonation while
bilateral palsy will result in complete adduction of the cords and stridor.

• Bilateral RLN palsy requires immediate reintubation and the patient may subsequently need a tracheostomy.

• HYPOCALCEMIA:

• Unintended trauma to the parathyroid glands may result in temporary hypocalcaemia. Permanent hypocalcaemia is
rare.

• Signs of hypocalcaemia may include confusion, twitching and tetany. This can be elicited in Trousseau’s or Chvostek’s
sign.

• Calcium replacement should be instituted immediately as hypocalcaemia can precipitate layngospasm, cardiac
irritability, QT prolongation and subsequent arrhythmias.
THANK

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